Doctors Management, LLC/Namas
Secure Payment Form
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Payment Summary
Payment Date
Payment Amount
Convenience Fee (3.75%)
Total Charge w/Convenience Fee
Business Name/Customer Name
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Account #/Invoice #/Description
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Credit Card Information
Name as on Card
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Card Billing Address
Card Billing Zip
Card Number
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Card Expiration Date
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CVV2/CID
Additional Information
Phone Number
Email Address
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